Clinical Investigation
Acute Ischemic Heart Disease
Real-world outcome from ST elevation myocardial infarction in the very elderly before and after the introduction of a 24/7 primary percutaneous coronary intervention service

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Background

It remains unclear whether the superiority of primary percutaneous coronary intervention (PPCI) over thrombolysis for the treatment of ST elevation myocardial infarction (STEMI) extends to the very elderly. Furthermore, the deliverability and efficacy of PPCI in over the 80s has not been investigated in a real-world setting. The aim of this study was to compare outcome from STEMI in patients aged ≥80 before and after the introduction of routine 24/7 PPCI.

Methods

Retrospective observational analysis of all patients aged ≥80 presenting with STEMI to 2 neighboring hospitals in the 3-year period after the introduction of a 24/7 PPCI service and in the preceding 2 years when reperfusion therapy was by thrombolysis.

Results

Two hundred fifty-six STEMI patients aged ≥80 were included. After the introduction of PPCI, 84% (136/161) received reperfusion therapy, 73% PPCI, and 12% thrombolysis, compared to 77% ([73/95] 1% PPCI, 76% thrombolysis) previously. Mortality after inception of PPCI was reduced at 12 months (29% vs 41%, P = .04) and 3 years (43% vs 58%, P = .02). Improved outcome was attributable to treatment by PPCI, which was associated with numerically lower 12-month (26% vs 37%, P = .07) and significantly reduced 3-year (42% vs 55%, P = .05) mortality compared to thrombolysis.

Conclusions

Primary PCI can be effectively delivered to very elderly patients presenting with ST elevation MI in a real-world setting and leads to a substantial reduction in mortality compared to patients treated by thrombolysis.

Section snippets

Study population

Consecutive patients aged ≥80 years admitted between March 2003 and March 2008 inclusive with a diagnosis of STEMI to 2 affiliated hospitals: one a large tertiary cardiac center, the other a district general hospital (DGH) in the same city. Patients were identified by retrospective analysis of our institutional database cross-referenced to a comprehensive United Kingdom myocardial infarction database (MINAP [Myocardial Infarction National Audit Project]).

Reperfusion treatment

Patients were divided into 2 cohorts

Baseline characteristics

A total of 256 patients (mean age 85 [range 80-97], 59% female, 97% white) were included in the analysis, 95 in the historical cohort and 161 in the contemporary group (Table I). Significantly more of the contemporary cohort were hypertensive (62% vs 47%, P = .03) and hyperlipidemic (34% vs 21%, P = .04). There was a higher incidence of prior MI among the historical cohort (32% vs 21%, P = .05). The incidence of cardiogenic shock was low but was numerically higher among the historical cohort

Discussion

This study found that introduction of a routine 24/7 PPCI service resulted in reduced long-term mortality among patients aged ≥80 presenting with STEMI. Improved outcome was driven by the significant reduction in mortality observed in patients treated by PPCI compared to those treated by thrombolysis.

The very elderly, defined as aged ≥80, represent an increasing proportion of patients admitted to hospital with STEMI, and their outcome is poor, with 30-day mortality of around 30%.12 However,

Conclusions

Introduction of a 24/7 PPCI service resulted in a significant reduction in 12-month and 3-year mortality in patients aged ≥80 presenting with STEMI, driven by superior outcomes in patients receiving reperfusion therapy with PPCI rather than thrombolysis. These data support the application of routine PPCI for the treatment of STEMI in the very elderly.

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